For a patient who started rabies Post-Exposure Prophylaxis (PEP) for a Category II exposure and received vaccine on Days 0, 3, and 7, and then had a new Category III exposure on Day 15, is Rabies Immunoglobulin (RIG) contraindicated after Day 7 of the first vaccine dose, regardless of the new exposure, and should the patient only continue with the vaccine series?

RIG Administration for New Category III Exposure After Day 7 of Initial PEP Series

For a patient who started rabies PEP for Category II exposure and then sustains a new Category III exposure on Day 15, RIG MUST be administered along with continuation of the vaccine series, because the "no RIG after Day 7" rule applies only to the same exposure episode, not to new, separate exposures that require immediate passive immunization. 1, 2

Critical Distinction: Same Exposure vs. New Exposure

The guideline statement that "RIG is not indicated beyond day 7" specifically refers to delayed administration of RIG for the same exposure episode, not to new exposures occurring after Day 7. 1 This is because:

• RIG can interfere with the active antibody response already underway from the initial exposure if given late in that same series 3
• However, a new exposure represents a completely separate event requiring immediate passive immunization to prevent viral entry into peripheral nerves at the new wound site 1, 2

Management Algorithm for Your Scenario

Step 1: Immediate Wound Care

• Wash all wounds thoroughly with soap and water for 15 minutes, followed by povidone-iodine irrigation if available 1, 2
• This is the single most effective measure for preventing rabies infection 1

Step 2: Determine "Previously Vaccinated" Status

Your patient is NOT considered "previously vaccinated" because they have only received a partial vaccine series (Days 0,3,7 of the initial Category II exposure). 2

• "Previously vaccinated" status requires completion of a full vaccine series (either pre-exposure or post-exposure with documented antibody response) 3, 2
• Partial vaccination does not confer full immune memory 2

Step 3: Administer Full Category III Prophylaxis

Because your patient is not yet "previously vaccinated," they require:

• RIG at 20 IU/kg body weight on Day 0 of the new exposure (which is Day 15 from the original series) 1, 2, 4
• Infiltrate as much RIG as anatomically feasible around and into the new wound(s) 3, 1, 4
• Any remaining RIG volume should be given intramuscularly at a site distant from vaccine administration 3, 1, 4
• Continue the vaccine series to complete the 4-dose schedule (Days 0,3,7,14 from the original start), and consider additional doses in consultation with rabies experts 1, 2

Why This Approach Is Correct

• The CDC recommends that each exposure be treated independently, with RIG administered for new Category III exposures even if they occur after Day 7 of the original PEP series 1
• A new Category III exposure requires immediate passive immunization because vaccine-induced antibodies from the partial series may not yet provide adequate protection at the new wound site 1, 2
• The patient has not completed a full vaccine series and therefore lacks the robust immunologic memory that would allow for the abbreviated 2-dose regimen without RIG 2

Critical Pitfall to Avoid

Do not withhold RIG based on the "no RIG after Day 7" rule when dealing with a new exposure. 1 This rule applies only to:

• Delayed administration of RIG for the same exposure (e.g., if RIG was not given on Day 0 but becomes available on Day 5) 3, 4, 5
• In that scenario, RIG can be given up to Day 7 of that exposure series 3, 4

Special Considerations

If Patient Were Immunocompromised

• Upgrade to a 5-dose vaccine regimen (Days 0,3,7,14,28) plus RIG at 20 IU/kg 3, 2
• Obtain serologic testing 7-14 days after final dose to confirm adequate antibody response 3, 2

If Patient Had Completed Full Prior Series

• Only then would the patient be considered "previously vaccinated" 3, 2
• In that case, give only 2 vaccine doses (Days 0 and 3) without RIG for the new exposure 3, 2
• RIG would suppress the anamnestic immune response in truly previously vaccinated persons 3

Administration Details

• Vaccine dose: 1.0 mL IM in deltoid (adults/older children) or anterolateral thigh (young children) 3, 2
• Never use gluteal area - associated with vaccine failure due to inadequate immune response 3, 2
• RIG and vaccine must not be administered in the same syringe or same anatomical site 3, 2, 4
• Do not exceed 20 IU/kg of RIG - higher doses suppress active antibody production 1, 2